Pediatricians against retail health clinics? It’s not that simple

One primary care option that can be both affordable and convenient for self-pay patients are retail health clinics such as Minute Clinic, Healthcare Clinic, and Target Clinic. These clinics typically treat a number of fairly simple illnesses and injuries, and are often located inside pharmacies. They’re most often staffed by a nurse practitioner who has a four-year nursing degree plus a masters degree in nursing.

I’ve written about retail health clinics before, and noted that while their training is definitely less than that of a doctor, they are a good choice for self-pay patients who just need someone who can diagnose and prescribe medicines for an ear infection or strep throat, or deal with a minor cut.

Well, in the past few days, the American Academy of Pediatrics (AAP) has weighed in on the growing use of retail health clinics, and they aren’t very happy about it. Here’s an excerpt from a story in the Wall Street Journal (subscription required):

Pediatrics Group Balks at Rise of Retail Health Clinics

Retail health clinics that are popping up in drugstores and other outlets shouldn’t be used for children’s primary-care needs, the American Academy of Pediatrics said, arguing that such facilities don’t provide the continuity of care that pediatricians do.

While retail clinics may be more convenient and less costly, the AAP said they are detrimental to the concept of a “medical home,” where patients have a personal physician who knows them well and coordinates all their care…

Set in drugstores, supermarkets and big-box stores, retail health clinics are playing a bigger role in the delivery of health care. Some have expanded beyond treating sore throats and giving flu shots to offer sports and school physicals and treat chronic diseases, setting up more direct competition with doctors.

Retail clinics also are generally open seven days a week, don’t require an appointment, accept more types of insurance than doctors do and charge 30% to 40% less for similar services, studies show. Costs vary widely by region and service offered, but getting a common ailment treated at a retail clinic, without insurance, typically runs between $50 and $75…

The root of the AAP’s concern seems to be that the nurse practitioner might miss something. Their statement explains that “…seemingly simple complaints may have serious underlying causes. Pediatricians also use routine visits to monitor and discuss other issues, such as mental health and obesity.”

Well, I think there is some truth to this – a nurse practitioner, having less training, may indeed miss something that a pediatrician might catch. But the same could be said further up the ladder – a pediatrician, who is basically a general practitioner with a focus on children, might miss something that a trained oncologist or ear-nose-throat doctor would catch because of their specialty training. And regardless of the level of training, health care professionals ranging from first-year nurses to specialists with decades of experience still miss things.

And I think AAP misses something else. It isn’t necessarily just a choice between going to see a nurse practitioner or a pediatrician, there’s a choice between going to the pediatrician or not going to see anyone at all because it’s too expensive or inaccessible. And it’s hard to argue that a child is better off not seeing anybody because there’s a slight chance they might miss something or fail to recognize a more serious underlying cause.

One of the things I like most about blogging is that it constantly forces me to question my assumptions. Writing so much, and reading so much, requires that I continuously go back and reassess what I think. There have been times, many of them in fact, when I have changed my mind or readjusted my biases.

So let’s talk about retail clinics. As a pediatrician, I’m supposed to hate them. You see, it’s hard to get into the whole medical home thing, and still tolerate their existence. We spend so much time in medicine talking about the doctor-patient relationship, stressing the continuity of care, that the idea of someone coming along and treating patients on the fly without any actual knowledge of them is somewhat repellent.

Not only that, but so much of what people, on both sides of the aisle, talk about to improve quality includes things like coordinated care, improved health records, better communication between specialists and primary care, etc. Almost none of these things are what retail clinics focus on. So I’ve always been a bit skeptical of how they should be promoted.

And then on Friday, my oldest child started complaining of a sore throat. My middle child also had been, but the positive predictive value of his complaints is notoriously low. I was instantly panicked. This was my first day back at work after vacation. I knew my wife was busy. How were we going to squeeze in two doctor’s visits into the middle of the day? Who was going to wait until the office opened to call and schedule them? I knew what the office was like. It would take hours.

There went the entire day.

But no! My wife said she’d just take them to the Minute Clinic to get swabbed on the way to school. They open at 8 AM. No appointments. It would take a few minutes and everyone would be on their way. Problem solved.

Huh? What happened to the medical home? What happened to continuity of care? What about the doctor-patient relationship?

It’s time to own up to the real world. It’s a sore throat. If it’s a virus, there’s really nothing to do but wait. If it’s strep throat, you want to treat it (to prevent long-term problems). But strep throat is one of the easiest things in the world to treat (Penicillin still works great!). There’s a simple and almost instantaneous test for it. And, get this, physicians are incredibly bad at diagnosing it clinically. A study found that a doctor’s guess as to whether pharyngitis is bacterial or viral is right about 50% percent of the time – no better than flipping a coin.

So this is one of those situations when, really, a mid-level practitioner is more than enough to swab the throat, make the call, and treat the disease. Plus, the minute clinic is in the pharmacy, so you can even get the antibiotics right then and there. Finally, as Austin noted last week, care at such clinics costs significantly less than a doctor’s visit and WAY less than a trip to the ED.

I’m sold. For strep throat, which accounted for 15 millionpatient visits in 2006 alone, retail clinics seem like a pretty good idea. While I still believe in the medical home and the importance of the doctor-patient relationship and continuity of care, I’m sure there are more examples of where they work as well.

That said, there are lots of examples where they won’t. Don’t take this as an excuse to go overboard.

To quote Dr. Carroll, I’m sold. Retail clinics of course have their limits, but for relatively minor illnesses and injuries, there’s nothing I’ve read that would stop me from taking my 3 ½ year old son to a retail clinic for a sore throat or a case of poison ivy. I should note that Minute Clinic, the largest operator of retail health clinics in the country, does say on their site that they don’t treat children under 18 months, and that’s probably a sensible precaution. I believe I’ve seen similar restrictions listed on other clinics’ web sites.

But parents who need convenient access to affordable, quality care for their children should still feel comfortable using a retail health clinic for basic services.

2 Responses to Pediatricians against retail health clinics? It’s not that simple

If somehow we are able to zoom out and look at the wider view, may be we can see:
-The new rules of healthcare have very conflicting INCENTIVES written into laws that we have to follow.
-Corporations with retail clinics or other provider outlets have the same incentive as the rest. It is self interest.
-Parents caring for their child have the same incentive. Also called self interest.
-Pediatricians and the AAP have the exact same incentive of self interest.
The decision maker in the parents has to decide who cares more about the sick child alongside their respective self interest. Sometimes they will make the right decision and always they will TRY to make the right one. Since they are able to use their money , in this particular case, then they remain FREE to choose. The AAP also chose, FREELY, to make it clear where they stand on the issue.
In brief, this is ALL GOOD

Considering the number of errors that full MD’s make, and I’ve been on the receiving end twice, my confidence in the medical profession is not that high. Part of the problem is being in too much of hurry, jumping to a conclusion without considering possible alternatives. As I’ve stated on my own blog, the “licensed professions” are the real “exploiter class” if you get down to it. They hold a legal lock over access to goods and services that would be illegal if done by any regular business. They cost the American people perhaps as much as a trillion dollars a year in extra costs, or $3,000 per capita. When you consider the amount of medical fraud that goes on, useless services that have no medical benefit, the cost to the American people is estimated to be 30% of all US health care costs. (figures given in a book by Rosemary Gibson & Janardan Singh).